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0 APPLICATION . �%Sjlyzlt � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JUN 1 S 19�� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388,STOCKTON, CA 95201-0388 ENVIRONMENTAL HEALTH PERMIT/SERVICES PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address17�CC Ls-.rimer \�oa.9 City�['a�� Lot Size/Acreage " 'A N$ A1, e S JAaCA Owner's Name USALF.- CE\\t,' Address \06w�.,... 1�c 41o,}sv.\\ t AL. Phone `\5S-S8e1 Contractor kZ,;-tc \'e.le\t�...,e...� ire,Address vJeoA\---� \ ts.\;�v�-. i.. License No. 3833'16 Phone q\b 661- x-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI (( DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � )\F Monitoring Well 0a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation aeE'r tx"d w' Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack 4?-,Tracy Type of Casing lcS t�� r S VV Specifications Se e0 weak,\•.-. ("1 Public I.1 Other n Delta Depth of Grout Seal .d..<:es "'/.-:a\\ Type of Grout 6it�'\•^•�t- •mac t I I longation _Approx. Depth I I Eastern Surface Seal Installed by We'ttc q,,-Ar R Repair Work Done ❑ Type of Pump _ qA H.P. WA State Work Done _ Well Destruction ❑ Well Diameter 4t4 t T v Sealing Material It Depth ;Os,, r. A. Depth Piller Material i Depth -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 IND septic system permitted if public sewer is available within 200 feet.) Installation will servZ _ Commercial _ Other Number of living unmbar of bedrooms Character of soil toeet: Water table depth SEPTIC TANK Mfg Capacity No. Compartments PKG. TREATMENT PMethod of Disposal ce to nearest: Well Foundation Property Line LEACHING LINE Length of lines Total length/size FILTER BED ce to nearest: Well Foun on Property Line SEEPAGE PITS 11 Depth Size umber SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature Certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X - Title: - Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public HealthServices Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 g m FEEa AMOUNT DUE CAAMOUNT REMITTED ASH EIVEDB RECV DATE PERMIl'N0. "' w EH 344 IREv,1/11 51 = EH Ur a! 1711 a